CHEST: Combat Vets' Sleep Problems Tied to Injury Type

Action Points

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Explain that the type of injury sustained by U.S. military personnel in the Middle East appears to be related to the types of sleep disturbances they experience when they return home.

Note that among soldiers with traumatic brain injury (TBI), blast injuries were associated with higher rates of anxiety and insomnia, and blunt trauma was associated with a higher rate of obstructive sleep apnea.

HONOLULU -- The type of injury sustained by U.S. military personnel in the Middle East appears to be related to the types of sleep disturbances they experience when they return home, researchers found.

Among soldiers with traumatic brain injury (TBI), blast injuries were associated with higher rates of anxiety and insomnia, and blunt trauma was associated with a higher rate of obstructive sleep apnea, according to Jacob Collen, MD, of Walter Reed National Military Medical Center in Bethesda, Md.

And among troops with posttraumatic stress disorder (PTSD), those who were not injured were more likely to receive a diagnosis of obstructive sleep apnea compared with their injured counterparts, Collen reported at the CHEST meeting here. He is an active-duty Army officer.

"Patients returning from combat with TBI or PTSD should undergo comprehensive sleep evaluations," he said, "and this will likely become more important as these patients leave the military healthcare system and encounter civilian providers."

Although it is well established that sleep-disordered breathing is more common in individuals with TBI or PTSD and that it generally slows recovery, previous studies have shown that obstructive sleep apnea remains underdiagnosed in military populations.

But there is limited information on veterans returning from the current conflicts: Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom.

Since the two wars began, there has been a dramatic increase in the diagnosis of sleep disorders among military personnel. In 2000, there were 3,563 cases of obstructive sleep apnea and 1,013 cases of insomnia in the military. Those numbers increased in 2009 to 20,435 and 19,613, respectively.

Collen and his colleagues wanted to take an in-depth look at sleep disturbances in returning soldiers with TBI or PTSD. They retrospectively reviewed the charts of 261 patients assigned to the Walter Reed Warrior Transition Brigade. Patients underwent a comprehensive sleep evaluation, which included polysomnography in about 80%.

The mean age of the soldiers was 35.6 and 90.4% were men with a mean body mass index of 29.28.

As seen previously, sleep complaints -- mostly poor sleep quality, fragmented sleep, or excessive daytime sleepiness -- were nearly universal, occurring in 95.8% of the patients. Insomnia was diagnosed in 48.7% and obstructive sleep apnea was diagnosed in 56.3%.

Most of the soldiers who had TBI (84.5%) had a mild injury. Comorbid psychiatric disease was prevalent: 56.9% had PTSD, 85.3% had depression, and 41.4% had anxiety. Almost all (94%) were on psychoactive medications. The average number of psychoactive medications per soldier was 3.1.

Of those with TBI who underwent polysomnography, obstructive sleep apnea was more prevalent in those with blunt trauma versus a blast injury. The difference remained significant in a multivariate analysis (OR 3.41, 95% CI 1.15 to 10.10).

The PTSD cohort was similar to the traumatic brain injury cohort in terms of high rates of depression and anxiety. About half also had TBI. More than half of those who underwent polysomnography (54.1%) were diagnosed with obstructive sleep apnea, with a higher rate in patients who were not injured.

Although the reason for that difference is not clear, Collen said his group has theorized that the obstructive sleep apnea was not diagnosed before deployment, which may serve as a risk factor for PTSD because of a lower physiologic reserve.

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